Readers of this News Blog may be aware that we are involved in the HiSLAC (high-intensity, specialist-led acute care) project that examines the impact of increasing consultant presence on acute in-hospital care at weekends.[1-4] Professor Julian Bion, the Principal Investigator for the project, recently drew our attention to two studies from the US that have shown some interesting results in relation to the potential impact of senior doctors on the quality of care. One of the studies was a cross-over randomised controlled trial (RCT) conducted in general medical wards in which increased supervision by attending physicians (senior doctors) was compared with standard supervision ; the other was a retrospective cohort study in which the association between physician’s age and patient outcomes was explored.
In the RCT, the attending physicians joined residents and interns (doctors who are still in training) on their ward rounds to see previously admitted (i.e. not newly admitted) patients in the increased supervision group, while the attending physicians were available but did not join the ward rounds in the standard supervision group. Medical error rates did not differ significantly between increased vs standard supervision (91 [95% CI 77 to 104] vs 108 [95% CI 86 to 134] events per 1000 patient-days), but interns (the most junior doctors) spoke significantly less, and both residents and interns felt that they were lessefficient and less autonomous in the ward rounds with increased supervision.
The retrospective cohort study was undertaken using a 20% random sample of Medicare (an US federal health insurance program primarily for elderly people) beneficiaries admitted to hospital with a medical condition and treated by hospitalists (senior doctors specialised in the general care of patients in hospitals). The association between the hospitalists’ age and 30-day mortality, 30-day re-admission and cost of care was explored with statistical adjustment covering patient characteristics, physician characteristics and hospital fixed effects (which essentially allows comparisons be made within hospitals). Adjusted 30-day mortality was found to increase with doctors’ age: 10.8%, 11.1%, 11.3% and 12.1% for ages <40, 40-49, 50-59 and ≥60 respectively. The association appears robust under various sensitivity and subgroup analyses, with an exception that no such association was found among doctors with a high volume of patients. Re-admission rates were similar between doctors’ age groups and costs of care were slightly higher among older doctors.
What should we make out of these findings? For the RCT, the observed effect (reduction in medical errors) was in the expected direction but the study was under-powered (the sample size was powered to detect a 40% relative reduction in error rates vs. 15% actually observed). However, the junior doctors clearly felt qualified to ‘fly solo’. For the observational study, while the association between doctors’ age and care quality and outcomes may require further scrutiny, it is highly speculative. Since an experimental study is not on the cards, cause and effect reasoning must await triangulation of multiple observations across the chain from cause to effect. Such a study is currently under way with respect to the cause of the “weekend effect”.
— Yen-Fu Chen, Principal Research Fellow
- Watson SI, Chen YF, Bion JF, Aldridge CP, Girling A, Lilford RJ. Protocol for the health economic evaluation of increasing the weekend specialist to patient ratio in hospitals in England. BMJ Open. 2018; 8: e015561.
- Bion J, Aldridge CP, Girling A, et al. Two-epoch cross-sectional case record review protocol comparing quality of care of hospital emergency admissions at weekends versus weekdays. BMJ Open. 2017; 7: e018747.
- Chen Y-F, Boyal A, Sutton E, et al. The magnitude and mechanisms of the weekend effect in hospital admissions: A protocol for a mixed methods review incorporating a systematic review and framework synthesis. Syst Rev. 2016; 5(1): 84.
- Tarrant C, Sutton E, Angell E, Aldridge CP, Boyal A, Bion J. The ‘weekend effect’ in acute medicine: a protocol for a team-based ethnography of weekend care for medical patients in acute hospital settings. BMJ Open.2017; 7(4): e016755.
- Finn KM, Metlay JP, Chang Y, et al. Effect of increased inpatient attending physician supervision on medical errors, patient safety, and resident education: a randomized clinical trial. JAMA Intern Med. 2018; 178(7): 952-59.
- Tsugawa Y, Newhouse JP, Zaslavsky AM, Blumenthal DM, Jena AB. Physician age and outcomes in elderly patients in hospital in the US: observational study. BMJ. 2017; 357: j1797.
- Lilford RJ, Chilton PJ, Hemming K, Girling AJ, Taylor CA, Barach P. Evaluating policy and service interventions: framework to guide selection and interpretation of study end points. BMJ. 2010; 341: c4413.
- Lilford RJ, Chen YF. The ubiquitous weekend effect: moving past proving it exists to clarifying what causes it. BMJ Qual Saf. 2015; 24(8): 480-2.